Basic Information
| Provider Information | |||||||||
| NPI: | 1427333038 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WING NEUROLOGICAL REHABILITATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SWAN REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1190 E MISSOURI AVE | ||||||||
| Address2: | 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142734 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 E MISSOURI AVE | ||||||||
| Address2: | 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023930520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2011 | ||||||||
| LastUpdateDate: | 10/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | WING | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6023930520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT, NCS, GCS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 9521 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.